Wearable cardioverter defibrillator (wcd) system measuring patient&#39;s respiration

ABSTRACT

A wearable cardioverter defibrillator (“WCD”) system may include an impedance detector configured to render an impedance signal of the patient. The WCD system may determine, from the impedance signal, a characteristic of breathing by the patient that can be used as a vital sign. The WCD system may determine, from at least the breathing characteristic, whether or not a shock criterion is met. If the shock criterion is met, the WCD system may control a discharge circuit to discharge a stored electrical charge through the patient. An advantage can be that the breathing characteristic may be used to determine whether or not a patient is experiencing a condition that requires defibrillation therapy, such as sudden cardiac arrest. Even more advantages can be had in discerning the state of the patient when the breathing characteristic is combined with other data, such as from a motion detector.

CROSS REFERENCE TO RELATED PATENT APPLICATIONS

This patent application is a Continuation Application of co-pending U.S.patent application Ser. No. 15/792,860, filed Oct. 25, 2017, whichclaims priority from U.S. Provisional Patent Application Ser. No.62/417,147, filed on Nov. 3, 2016, now expired; the disclosure of eachapplication which, as initially made, is hereby incorporated byreference.

BACKGROUND

When people suffer from some types of heart arrhythmias, the result maybe that blood flow to various parts of the body is reduced. Somearrhythmias may even result in a Sudden Cardiac Arrest (SCA). SCA canlead to death very quickly, e.g. within 10 minutes, unless treated inthe interim.

Some people have an increased risk of SCA. People at a higher riskinclude patients who have had a heart attack, or a prior SCA episode. Afrequent recommendation is for these people to receive an ImplantableCardioverter Defibrillator (ICD). The ICD is surgically implanted in thechest, and continuously monitors the patient's electrocardiogram (ECG)signal, which is sometimes simply called ECG. If certain types of heartarrhythmias are detected, then the ICD delivers an electric shockthrough the heart.

After being identified as having an increased risk of an SCA, and beforereceiving an ICD, these people are sometimes given a WearableCardioverter Defibrillator (WCD) system. (Early versions of such systemswere called wearable cardiac defibrillator systems.) A WCD systemtypically includes a harness, vest, or other garment that the patient isto wear. The WCD system further includes electronic components, such asa defibrillator and electrodes, coupled to the harness, vest, or othergarment. When the patient wears the WCD system, the external electrodesmay then make good electrical contact with the patient's skin, andtherefore can help determine the patient's ECG. If a shockable heartarrhythmia is detected, then the defibrillator delivers the appropriateelectric shock through the patient's body, and thus through the heart.

One of the challenges in developing a WCD system is to determineaccurately what patient is experiencing, and therefore to determinewhether or not they require defibrillation therapy. With ambulatorypatients, there are many sources of noise that can make this difficultby analyzing the ECG waveform alone.

All subject matter discussed in this Background section of this documentis not necessarily prior art, and may not be presumed to be prior art,simply because it is presented in this Background section. Plus, anyreference to any prior art in this description is not, and should not betaken as, an acknowledgement or any form of suggestion that such priorart forms parts of the common general knowledge in any country or anyart. Along these lines, any recognition of problems in the prior artdiscussed in this Background section or associated with such subjectmatter should not be treated as prior art, unless expressly stated to beprior art. Rather, the discussion of any subject matter in thisBackground section should be treated as part of the approach takentowards the particular problem by the inventors. This approach in and ofitself may also be inventive.

BRIEF SUMMARY

The present description gives instances of Wearable CardioverterDefibrillator (WCD) systems, storage media that store programs, andmethods, the use of which may help overcome problems and limitations ofthe prior art.

In embodiments, a wearable cardioverter defibrillator (“WCD”) systemincludes an impedance detector configured to render an impedance signalof the patient. The WCD system may determine, from the impedance signal,a characteristic of breathing by the patient that can be used as a vitalsign. The WCD system may determine, from at least the breathingcharacteristic, whether or not a shock criterion is met. If the shockcriterion is met, the WCD system may control a discharge circuit todischarge a stored electrical charge through the patient.

An advantage can be that the breathing characteristic may be used todetermine whether or not a patient is experiencing a condition thatrequires defibrillation therapy, such as sudden cardiac arrest. Evenmore advantages can be had in discerning the state of the patient whenthe breathing characteristic is combined with other data, such as from amotion detector.

These and other features and advantages of the claimed invention willbecome more readily apparent in view of the embodiments described andillustrated in the present disclosure, namely from the present writtenspecification and the drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram of components of a sample wearable cardioverterdefibrillator (WCD) system, made according to embodiments.

FIG. 2 is a diagram showing sample components of an externaldefibrillator, such as the one belonging in the system of FIG. 1, andwhich is made according to embodiments.

FIG. 3 shows a flowchart for illustrating methods according toembodiments, the flowchart annotated with icons of elements that can berelated to individual operations of the flowchart.

FIG. 4A is a time diagram of a sample rendered ECG signal, furtherannotated to indicate a shifting baseline that may be identified andused in filtering operations according to embodiments.

FIG. 4B is a time diagram of a sample rendered motion detection signalor input, further annotated to indicate an identified motionless timeperiod, during which a baseline value of a breathing characteristic maybe determined according to embodiments.

FIG. 5 is a time diagram of a sample impedance signal, annotated toillustrate how a breathing characteristic is determined according toembodiments.

FIG. 6 is a time diagram of a sample impedance signal, annotated toillustrate how another breathing characteristic is determined accordingto embodiments.

FIG. 7 is a time diagram of a sample impedance signal, annotated toillustrate how one more breathing characteristic is determined accordingto embodiments.

FIG. 8 illustrates how a sample value of a determined breathingcharacteristic may be used for performing operations according toembodiments.

FIG. 9 illustrates how changes in a sample value of a determinedbreathing characteristic may be used for performing operations accordingto embodiments.

DETAILED DESCRIPTION

As has been mentioned, the present description is about WearableCardioverter Defibrillator (WCD) systems, storage media that storeprograms, and methods. Embodiments are now described in more detail.

A wearable cardioverter defibrillator (WCD) system made according toembodiments has a number of components. These components can be providedseparately as modules that can be interconnected, or can be combinedwith other components, etc.

FIG. 1 depicts a patient 82. Patient 82 may also be referred to as aperson and/or wearer, since that patient wears components of the WCDsystem. Patient 82 is ambulatory, which means patient 82 can walkaround, and is not necessarily bed-ridden.

FIG. 1 also depicts components of a WCD system made according toembodiments. One such component is a support structure 170 that iswearable by patient 82. It will be understood that support structure 170is shown only generically in FIG. 1, and in fact partly conceptually.FIG. 1 is provided merely to illustrate concepts about support structure170, and is not to be construed as limiting how support structure 170 isimplemented, or how it is worn.

Support structure 170 can be implemented in many different ways. Forexample, it can be implemented in a single component or a combination ofmultiple components. In embodiments, support structure 170 could includea vest, a half-vest, a garment, etc. In such embodiments such items canbe worn similarly to parallel articles of clothing. In embodiments,support structure 170 could include a harness, one or more belts orstraps, etc. In such embodiments, such items can be worn by the patientaround the torso, hips, over the shoulder, etc. In embodiments, supportstructure 170 can include a container or housing, which can even bewaterproof. In such embodiments, the support structure can be worn bybeing attached to the patient by adhesive material, for example as shownin U.S. Pat. No. 8,024,037. Support structure 170 can even beimplemented as described for the support structure of US Pat. App. No.US 2017/0056682 A1, which is incorporated herein by reference. Ofcourse, in such embodiments, the person skilled in the art willrecognize that additional components of the WCD system can be in thehousing of a support structure instead of being attached externally tothe support structure, for example as described in the 2017/0056682document. There can be other examples.

A WCD system according to embodiments is configured to defibrillate apatient who is wearing it, by delivering an electrical charge to thepatient's body in the form of an electric shock delivered in one or morepulses. FIG. 1 shows a sample external defibrillator 100, and sampledefibrillation electrodes 104, 108, which are coupled to externaldefibrillator 100 via electrode leads 105. Defibrillator 100 anddefibrillation electrodes 104, 108 can be coupled to support structure170. As such, many of the components of defibrillator 100 could betherefore coupled to support structure 170. When defibrillationelectrodes 104, 108 make good electrical contact with the body ofpatient 82, defibrillator 100 can administer, via electrodes 104, 108, abrief, strong electric pulse 111 through the body. Pulse 111, also knownas shock, defibrillation shock, therapy or therapy shock, is intended togo through and restart heart 85, in an effort to save the life ofpatient 82. Pulse 111 can further include one or more pacing pulses, andso on.

A prior art defibrillator typically decides whether to defibrillate ornot based on an ECG signal of the patient. However, externaldefibrillator 100 may initiate defibrillation (or hold-offdefibrillation) based on a variety of inputs, with ECG merely being oneof them.

Accordingly, it will be appreciated that signals such as physiologicalsignals containing physiological data can be obtained from patient 82.While the patient may be considered also a “user” of the WCD system,this is not a requirement. That is, for example, a user of the wearablecardioverter defibrillator (WCD) may include a clinician such as adoctor, nurse, emergency medical technician (EMT) or other similarlysituated individual (or group of individuals). The particular context ofthese and other related terms within this description should beinterpreted accordingly.

The WCD system may optionally include an outside monitoring device 180.Device 180 is called an “outside” device because it could be provided asa standalone device, for example not within the housing of defibrillator100. Device 180 can be configured to sense or monitor at least one localparameter. A local parameter can be a parameter of patient 82, or aparameter of the WCD system, or a parameter of the environment, as willbe described later in this document. Device 180 may include one or moretransducers or sensors that are configured to render one or morephysiological inputs or signals from one or more patient parameters thatthey sense.

Optionally, device 180 is physically coupled to support structure 170.In addition, device 180 can be communicatively coupled with othercomponents, which are coupled to support structure 170. Suchcommunication can be implemented by a communication module, as will bedeemed applicable by a person skilled in the art in view of thisdescription.

FIG. 2 is a diagram showing components of an external defibrillator 200,made according to embodiments. These components can be, for example,included in external defibrillator 100 of FIG. 1. The components shownin FIG. 2 can be provided in a housing 201, which may also be referredto as casing 201.

External defibrillator 200 is intended for a patient who would bewearing it, such as patient 82 of FIG. 1. Defibrillator 200 may furtherinclude a user interface 280 for a user 282. User 282 can be patient 82,also known as wearer 82. Or, user 282 can be a local rescuer at thescene, such as a bystander who might offer assistance, or a trainedperson. Or, user 282 might be a remotely located trained caregiver incommunication with the WCD system.

User interface 280 can be made in a number of ways. User interface 280may include output devices, which can be visual, audible or tactile, forcommunicating to a user by outputting images, sounds or vibrations.Images, sounds, vibrations, and anything that can be perceived by user282 can also be called human-perceptible indications. There are manyexamples of output devices. For example, an output device can be alight, or a screen to display what is sensed, detected and/or measured,and provide visual feedback to rescuer 282 for their resuscitationattempts, and so on.

Another output device can be a speaker, which can be configured to issuevoice prompts, beeps, loud alarm sounds and/or words to warn bystanders,etc.

User interface 280 may further include input devices for receivinginputs from users. Such input devices may additionally include variouscontrols, such as pushbuttons, keyboards, touchscreens, one or moremicrophones, and so on. An input device can be a cancel switch, which issometimes called an “I am alive” switch or “live man” switch. In someembodiments, actuating the cancel switch can prevent the impendingdelivery of a shock.

Defibrillator 200 may include an internal monitoring device 281. Device281 is called an “internal” device because it is incorporated withinhousing 201. Monitoring device 281 can sense or monitor patientparameters such as patient physiological parameters, system parametersand/or environmental parameters, all of which can be called patientdata. In other words, internal monitoring device 281 can becomplementary or an alternative to outside monitoring device 180 ofFIG. 1. Allocating which of the parameters are to be monitored by whichof monitoring devices 180, 281 can be done according to designconsiderations. Device 281 may include one or more transducers orsensors that are configured to render one or more physiological inputsfrom one or more patient parameters that it senses.

Patient parameters may include patient physiological parameters. Patientphysiological parameters may include, for example and withoutlimitation, those physiological parameters that can be of any help indetecting by the wearable defibrillation system whether the patient isin need of a shock, plus optionally their medical history and/or eventhistory. Examples of such parameters include the patient's ECG, bloodoxygen level, blood flow, blood pressure, blood perfusion, pulsatilechange in light transmission or reflection properties of perfusedtissue, heart sounds, heart wall motion, breathing sounds and pulse.Accordingly, monitoring devices 180, 281 may include one or more sensorsconfigured to acquire patient physiological signals. Examples of suchsensors or transducers include electrodes to detect ECG data, aperfusion sensor, a pulse oximeter, a device for detecting blood flow(e.g. a Doppler device), a sensor for detecting blood pressure (e.g. acuff), an optical sensor, illumination detectors and sensors perhapsworking together with light sources for detecting color change intissue, a motion sensor, a device that can detect heart wall movement, asound sensor, a device with a microphone, an SpO₂ sensor, and so on. Inview of this disclosure, it will be appreciated that such sensors canhelp detect the patient's pulse, and can therefore also be called pulsedetection sensors, pulse sensors, and pulse rate sensors. Pulsedetection is also taught at least in Physio-Control's U.S. Pat. No.8,135,462, which is hereby incorporated by reference in its entirety. Inaddition, a person skilled in the art may implement other ways ofperforming pulse detection. In such cases, the transducer includes anappropriate sensor, and the physiological input is a measurement by thesensor of that patient parameter. For example, the appropriate sensorfor a heart sound may include a microphone, etc.

In some embodiments, the local parameter is a trend that can be detectedin a monitored physiological parameter of patient 282. A trend can bedetected by comparing values of parameters at different times.Parameters whose detected trends can particularly help a cardiacrehabilitation program include: a) cardiac function (e.g. ejectionfraction, stroke volume, cardiac output, etc.); b) heart ratevariability at rest or during exercise; c) heart rate profile duringexercise and measurement of activity vigor, such as from the profile ofan accelerometer signal and informed from adaptive rate pacemakertechnology; d) heart rate trending; e) perfusion, such as from SpO₂ orCO₂; f) respiratory function, respiration rate, etc.; g) motion, levelof activity; and so on. Once a trend is detected, it can be storedand/or reported via a communication link, along perhaps with a warning.From the report, a physician monitoring the progress of patient 282 willknow about a condition that is either not improving or deteriorating.

Patient state parameters include recorded aspects of patient 282, suchas motion, posture, whether they have spoken recently plus maybe alsowhat they said, and so on, plus optionally the history of theseparameters. Or, one of these monitoring devices could include a locationsensor such as a Global Positioning System (GPS) location sensor. Such asensor can detect the location, plus a speed can be detected as a rateof change of location over time. Many motion detectors output a motionsignal that is indicative of the motion of the detector, and thus of thepatient's body. Patient state parameters can be very helpful innarrowing down the determination of whether SCA is indeed taking place.

A WCD system made according to embodiments may include a motiondetector. In embodiments, a motion detector can be implemented withinmonitoring device 180 or monitoring device 281. Such a motion detectorcan be made in many ways as is known in the art, for example by using anaccelerometer. In this example, a motion detector 287 is implementedwithin monitoring device 281.

A motion detector of a WCD system according to embodiments can beconfigured to detect a motion event, or motion in general. In response,the motion detector may render or generate, from the detected motionevent or motion, a motion detection input or signal that can be receivedby a subsequent device or functionality. A motion event can be definedas is convenient, for example a change in motion from a baseline motionor rest, etc. In such cases, the patient parameter is a motion.

System parameters of a WCD system can include system identification,battery status, system date and time, reports of self-testing, recordsof data entered, records of episodes and intervention, and so on.

Environmental parameters can include ambient temperature and pressure.Moreover, a humidity sensor may provide information as to whether it islikely raining. Presumed patient location could also be considered anenvironmental parameter. The patient location could be presumed, ifmonitoring device 180 or 281 includes a GPS location sensor as per theabove, and if it is presumed that the patient is wearing the WCD system.

Defibrillator 200 typically includes a defibrillation port 210, such asa socket in housing 201. Defibrillation port 210 includes electricalnodes 214, 218. Leads of defibrillation electrodes 204, 208, such asleads 105 of FIG. 1, can be plugged into defibrillation port 210, so asto make electrical contact with nodes 214, 218, respectively. It is alsopossible that defibrillation electrodes 204, 208 are connectedcontinuously to defibrillation port 210, instead. Either way,defibrillation port 210 can be used for guiding, via electrodes, to thewearer the electrical charge that has been stored in an energy storagemodule 250 that is described more fully later in this document. Theelectric charge will be the shock for defibrillation, pacing, and so on.

Defibrillator 200 may optionally also have a sensor port 219 in housing201, which is also sometimes known as an ECG port. Sensor port 219 canbe adapted for plugging in sensing electrodes 209, which are also knownas ECG electrodes and ECG leads. It is also possible that sensingelectrodes 209 can be connected continuously to sensor port 219,instead. Sensing electrodes 209 are types of transducers that can helpsense an ECG signal or an impedance signal. The ECG signal may be, forexample, a 12-lead signal, or a signal from a different number of leads,especially if they make good electrical contact with the body of thepatient. Sensing electrodes 209 can be attached to the inside of supportstructure 170 for making good electrical contact with the patient,similarly with defibrillation electrodes 204, 208.

Optionally a WCD system according to embodiments also includes a fluidthat it can deploy automatically between the electrodes and thepatient's skin. The fluid can be conductive, such as by including anelectrolyte, for establishing a better electrical contact between theelectrode and the skin. Electrically speaking, when the fluid isdeployed, the electrical impedance between the electrode and the skin isreduced. Mechanically speaking, the fluid may be in the form of alow-viscosity gel, so that it does not flow away from the electrode,after it has been deployed. The fluid can be used for bothdefibrillation electrodes 204, 208, and for sensing electrodes 209.

The fluid may be initially stored in a fluid reservoir, not shown inFIG. 2, which can be coupled to the support structure. In addition, aWCD system according to embodiments further includes a fluid deployingmechanism 274. Fluid deploying mechanism 274 can be configured to causeat least some of the fluid to be released from the reservoir, and bedeployed near one or both of the patient locations, to which theelectrodes are configured to be attached to the patient. In someembodiments, fluid deploying mechanism 274 is activated prior to theelectrical discharge responsive to receiving activation signal AS from aprocessor 230, which is described more fully later in this document.

In some embodiments, defibrillator 200 also includes a measurementcircuit 220, as one or more of its sensors or transducers. Measurementcircuit 220 senses one or more electrical physiological signals of thepatient from sensor port 219, if provided. Even if defibrillator 200lacks sensor port 219, measurement circuit 220 may optionally obtainphysiological signals through nodes 214, 218 instead, whendefibrillation electrodes 204, 208 are attached to the patient. In thesecases, the physiological input may reflect an ECG measurement. Thepatient parameter can be an ECG, which can be sensed as a voltagedifference between electrodes 204, 208.

Measurement circuit 220 may also include an impedance detector 222. Assuch, the patient parameter can be an impedance, which can be sensedbetween electrodes 204, 208 and/or the connections of sensor port 219.Sensing the impedance can be useful for detecting, among other things,whether these electrodes 204, 208 and/or sensing electrodes 209 are notmaking good electrical contact with the patient's body. In embodiments,impedance detector 222 is configured to render an impedance signal 223of the patient. The impedance signal can be rendered as a modulation toa carrier signal, as a stream of values, and so on.

These patient physiological signals can be sensed, when available.Measurement circuit 220 can then render or generate information aboutthem as physiological inputs, data, other signals, etc. More strictlyspeaking, the information rendered by measurement circuit 220 is outputfrom it, but this information can be called an input because it isreceived by a subsequent device or functionality as an input.

In some embodiments, defibrillator 200 also includes a stand-alonefilter 228. Filter 228 can be configured to receive signals rendered bymeasurement circuit 220, such as the ECG signal, impedance signal 223,and so on. Filter 228 can be configured to derive a filtered impedancesignal from the rendered impedance signal. The filtered impedance signalmay correspond to the rendered impedance signal, with at least a portionof the rendered impedance signal changed. Alternately, filtering signalsmay be accomplished by processing numbers within a processor, such as isdescribed below.

Defibrillator 200 also includes a processor 230. Processor 230 may beimplemented in a number of ways. Such ways include, by way of exampleand not of limitation, digital and/or analog processors such asmicroprocessors and Digital Signal Processors (DSPs); controllers suchas microcontrollers; software running in a machine; programmablecircuits such as Field Programmable Gate Arrays (FPGAs),Field-Programmable Analog Arrays (FPAAs), Programmable Logic Devices(PLDs), Application Specific Integrated Circuits (ASICs), anycombination of one or more of these, and so on.

Processor 230 may include, or have access to, a non-transitory storagemedium, such as memory 238 that is described more fully later in thisdocument. Such a memory can have a non-volatile component for storage ofmachine-readable and machine-executable instructions. A set of suchinstructions can also be called a program. The instructions, which mayalso be referred to as “software,” generally provide functionality byperforming methods as may be disclosed herein or understood by oneskilled in the art in view of the disclosed embodiments. In someembodiments, and as a matter of convention used herein, instances of thesoftware may be referred to as a “module” and by other similar terms.Generally, a module includes a set of the instructions so as to offer orfulfill a particular functionality. Embodiments of modules and thefunctionality delivered are not limited by the embodiments described inthis document.

Processor 230 can be considered to have a number of modules. One suchmodule can be a detection module 232. Detection module 232 can include aVentricular Fibrillation (VF) detector. The patient's sensed ECG frommeasurement circuit 220, which can be available as physiological inputs,data, or other signals, may be used by the VF detector to determinewhether the patient is experiencing VF. Detecting VF is useful, becauseVF typically results in SCA. Detection module 232 can also include aVentricular Tachycardia (VT) detector, and so on.

Another such module in processor 230 can be an advice module 234, whichgenerates advice for what to do. The advice can be based on outputs ofdetection module 232. There can be many types of advice according toembodiments. In some embodiments, the advice is a shock/no shockdetermination that processor 230 can make, for example via advice module234. The shock/no shock determination can be made by executing a storedShock Advisory Algorithm. A Shock Advisory Algorithm can make a shock/noshock determination from one or more ECG signals that are capturedaccording to embodiments, and determining whether a shock criterion ismet. The determination can be made from a rhythm analysis of thecaptured ECG signal or otherwise.

In some embodiments, when the determination is to shock, an electricalcharge is delivered to the patient. Delivering the electrical charge isalso known as discharging. Shocking can be for defibrillation, pacing,and so on.

Processor 230 can include additional modules, such as other module 236,for other functions. In addition, if internal monitoring device 281 isindeed provided, it may be operated in part by processor 230, etc.

Defibrillator 200 optionally further includes a memory 238, which canwork together with processor 230. Memory 238 may be implemented in anumber of ways. Such ways include, by way of example and not oflimitation, volatile memories, Nonvolatile Memories (NVM), Read-OnlyMemories (ROM), Random Access Memories (RAM), magnetic disk storagemedia, optical storage media, smart cards, flash memory devices, anycombination of these, and so on. Memory 238 is thus a non-transitorystorage medium. Memory 238, if provided, can include programs forprocessor 230, which processor 230 may be able to read and execute. Moreparticularly, the programs can include sets of instructions in the formof code, which processor 230 may be able to execute upon reading.Executing is performed by physical manipulations of physical quantities,and may result in functions, operations, processes, actions and/ormethods to be performed, and/or the processor to cause other devices orcomponents or blocks to perform such functions, operations, processes,actions and/or methods. The programs can be operational for the inherentneeds of processor 230, and can also include protocols and ways thatdecisions can be made by advice module 234. In addition, memory 238 canstore prompts for user 282, if this user is a local rescuer. Moreover,memory 238 can store data. This data can include patient data, systemdata and environmental data, for example as learned by internalmonitoring device 281 and outside monitoring device 180. The data can bestored in memory 238 before it is transmitted out of defibrillator 200,or stored there after it is received by defibrillator 200.

Defibrillator 200 may also include a power source 240. To enableportability of defibrillator 200, power source 240 typically includes abattery. Such a battery is typically implemented as a battery pack,which can be rechargeable or not. Sometimes a combination is used ofrechargeable and non-rechargeable battery packs. Other embodiments ofpower source 240 can include an AC power override, for where AC powerwill be available, an energy-storing capacitor, and so on. In someembodiments, power source 240 is controlled by processor 230.Appropriate components may be included to provide for charging orreplacing power source 240.

Defibrillator 200 may additionally include an energy storage module 250.Energy storage module 250 can be coupled to the support structure of theWCD system, for example either directly or via the electrodes and theirleads. Module 250 is where some electrical energy can be storedtemporarily in the form of an electrical charge, when preparing it fordischarge to administer a shock. In embodiments, module 250 can becharged from power source 240 to the desired amount of energy, ascontrolled by processor 230. In typical implementations, module 250includes a capacitor 252, which can be a single capacitor or a system ofcapacitors, and so on. In some embodiments, energy storage module 250includes a device that exhibits high power density, such as anultracapacitor. As described above, capacitor 252 can store the energyin the form of an electrical charge, for delivering to the patient.

Defibrillator 200 moreover includes a discharge circuit 255. When thedecision is to shock, processor 230 can be configured to controldischarge circuit 255 to discharge through the patient the electricalcharge stored in energy storage module 250. When so controlled, circuit255 can permit the energy stored in module 250 to be discharged to nodes214, 218, and from there also to defibrillation electrodes 204, 208, soas to cause a shock to be delivered to the patient. Circuit 255 caninclude one or more switches 257. Switches 257 can be made in a numberof ways, such as by an H-bridge, and so on. Circuit 255 can also becontrolled via user interface 280.

Defibrillator 200 can optionally include a communication module 290, forestablishing one or more wired or wireless communication links withother devices of other entities, such as a remote assistance center,Emergency Medical Services (EMS), and so on. The data can includepatient data, event information, therapy attempted, CPR performance,system data, environmental data, and so on. For example, communicationmodule 290 may transmit wirelessly, on a daily basis, heart rate,respiratory rate, and other vital signs data to a server accessible overthe internet, for instance as described in US 20140043149. This data canbe analyzed directly by the patient's physician and can also be analyzedautomatically by algorithms designed to detect a developing illness andthen notify medical personnel via text, email, phone, etc. In addition,communication module 290 may also have the capability to contactemergency services when an episode of sudden cardiac death is detectedor other critical illnesses are detected. Module 290 may also includesuch interconnected sub-components as may be deemed necessary by aperson skilled in the art, for example an antenna, portions of aprocessor, supporting electronics, outlet for a telephone or a networkcable, etc. This way, data, commands, etc. can be communicated.

Defibrillator 200 can optionally include other components.

Returning to FIG. 1, in embodiments, one or more of the components ofthe shown WCD system have been customized for patient 82. Thiscustomization may include a number of aspects. For instance, supportstructure 170 can be fitted to the body of patient 82. For anotherinstance, baseline physiological parameters of patient 82 can bemeasured, such as the heart rate of patient 82 while resting, whilewalking, motion detector outputs while walking, etc. Such baselinephysiological parameters can be used to customize the WCD system, inorder to make its diagnoses more accurate, since the patients' bodiesdiffer from one another. Of course, such parameters can be stored in amemory of the WCD system, and so on.

A programming interface can be made according to embodiments, whichreceives such measured baseline physiological parameters. Such aprogramming interface may input automatically in the WCD system thebaseline physiological parameters, along with other data.

The devices and/or systems mentioned in this document perform functions,processes and/or methods. These functions, processes and/or methods maybe implemented by one or more devices that include logic circuitry. Sucha device can be alternately called a computer, and so on. It may be astandalone device or computer, such as a general purpose computer, orpart of a device that has one or more additional functions. The logiccircuitry may include a processor and non-transitory computer-readablestorage media, such as memories, of the type described elsewhere in thisdocument. Often, for the sake of convenience only, it is preferred toimplement and describe a program as various interconnected distinctsoftware modules or features. These, along with data are individuallyand also collectively known as software. In some instances, software iscombined with hardware, in a mix called firmware.

Moreover, methods and algorithms are described below. These methods andalgorithms are not necessarily inherently associated with any particularlogic device or other apparatus. Rather, they are advantageouslyimplemented by programs for use by a computing machine, such as ageneral-purpose computer, a special purpose computer, a microprocessor,a processor such as described elsewhere in this document, and so on.

This detailed description includes flowcharts, display images,algorithms, and symbolic representations of program operations within atleast one computer readable medium. An economy is achieved in that asingle set of flowcharts is used to describe both programs, and alsomethods. So, while flowcharts described methods in terms of boxes, theyalso concurrently describe programs.

Methods are now described.

FIG. 3 shows a flowchart 300 for illustrating methods according toembodiments. Flowchart 300 includes operations that are linked byarrows. A vertical line 302 is at the right side of flowchart 300.Further to the right of vertical line 302 are shown icons of elementsthat can be related to individual operations of flowchart 300. Theseicons are indicated as linked with their respective operations by usingwider arrows that cross line 302. These wider arrows, however, do notform part of flowchart 300.

FIG. 3 starts with an optional operation 310, according to which arendered impedance signal 323 may be filtered, to derive a filteredimpedance signal 315. Rendered impedance signal 323 may be the impedancesignal rendered by an impedance detector, such as impedance signal 223.

The filtering of operation 310 may be performed in a number of ways. Forexample, filtered impedance signal 315 may be derived by removing fromrendered impedance signal 323 variations that have a frequency greaterthan a threshold frequency, such as 10 Hz. Or, filtered impedance signal315 may be derived by removing from rendered impedance 323 signalvariations that repeat over a period of at least 30 seconds.

In some embodiments, filtering is informed by another, concurrent signalfrom another transducer. Two examples are developed in this document,although more are possible.

First, referring tentatively to FIG. 4A, a WCD system may furtherinclude a transducer configured to render an electrocardiogram (ECG)signal 406 of the patient, such as sensing electrodes 209 in combinationwith measurement circuit 220, etc. In signal 406, QRS complexes 411maybe identified. In addition, variations in a baseline of ECG signal406 may be identified. For example, a line segment 422 shows an instancewhere the baseline of signal 406 is shifting. In this instance, linesegment 422 is largely defined between the two identified QRS complexes411, but that is coincidental; in fact, such line segments may bedefined at other times of signal 406. The filtered impedance signal,then, may be derived by removing from the rendered impedance signalvariations that are concurrent with the identified variations of ECGsignal 406, variations such as indicated by line segment 422. In otherwords, the slope of line segment 422 may inform a filtering operation410, which may be performed as operation 310.

For a second example, a WCD system may further include a motiondetector, such as was described above. Variations may be identified inthe motion detection signal. The filtered impedance signal may bederived by removing from the rendered impedance signal variations thatare concurrent with the identified variations in the motion detectionsignal.

Returning to FIG. 3, after optional operation 310, according to anotheroperation 320, an impedance signal of the patient may be input. Theimpedance signal input at operation 320 may be rendered impedance signal323, if optional operation 310 is not performed. Alternately, theimpedance signal input at operation 320 may be filtered impedance signal315, instead of rendered impedance signal 323.

According to another operation 330, a characteristic of breathing 335 bythe patient may be determined from the impedance signal input atoperation 320. If operation 310 has been performed, characteristic 335is determined from filtered impedance signal 315, instead of fromrendered impedance signal 323.

According to another, optional operation 340, it may be determinedwhether or not breathing characteristic 335 meets an alarm condition. Ifthe answer at operation 340 is YES then, according to another, optionaloperation 345, a follow-up action may be caused to be executed. In otherwords, the follow-up action may be caused to be executed responsive todetermining that the alarm condition is thus met at operation 340.Examples are given later in this document.

After operation 345, or if the answer at operation 340 is NO then,according to another, optional operation 360, a value of breathingcharacteristic 335 may be stored in a memory, such as memory 238. Notethat this operation 360 may store values as a matter of record. In someinstances, some of these stored values may be used to form a baselinefor comparison.

According to another operation 380, it may be determined whether or nota shock criterion is met. If at operation 380 the answer is NO, thenexecution may return to a previous operation, such as operation 310.Else, if at operation 380 the answer is YES, then according to anotheroperation 390, a discharge circuit such as discharge circuit 255 may becontrolled to discharge stored electrical charge through the patient,while the support structure is worn by the patient. This would deliverelectrical therapy.

The determination of operation 380 may be further performed in a numberof ways. Examples are now described.

In some embodiments, the determination of operation 380 is performedfrom at least breathing characteristic 335. For instance, a baselinevalue for breathing characteristic 335 may be stored in a memory, suchas memory 238. Then a difference may be computed of a current value ofthe breathing characteristic and the stored baseline value. Then it maybe determined at least in part that the shock criterion is met,responsive to the computed difference being larger than a threshold.

A baseline value for breathing characteristic 335 may be a set value, ora value customized to the patient by training the WCD system or byseparately evaluating the patient. For example, referring now to FIG.4B, a time diagram is shown of a sample rendered motion detection signal405, which is also called motion detection input 405. Three time domains441, 442, 443 are identified. A motion event is detected in time domain442. Signal 405 could indicate that the patient rose from a chair,walked four steps to another chair, and then sat down again.Motionlessness is detected in time domains 441 & 443. In suchembodiments, a baseline value for breathing characteristic 335 may bedetermined from a portion of an impedance signal, to be discussed later,in view of a portion of motion detection signal 405 relative to theportion of the impedance signal. For example, time domain 443 ofmotionlessness may be used to inform when a storing operation 460 may beperformed for purposes of developing a baseline. Otherwise, operation460 may be performed as described for operation 360. As such, theabove-mentioned portion of the impedance signal may be concurrent with aportion of motion detection signal 405 that is motionless, such asduring time periods 441 & 443, or presumed walking, such as during timeperiod 442, and so on. Different baseline values may be stored fordifferent activities.

In some embodiments, the determination of operation 380 is performedfrom also another input 379. Input 379 may be derived from a transducerconfigured to render an input from a sensed parameter of the patient,the input being distinct from the impedance signal. The processor may beable to determine from at least input 379 and breathing characteristic335 whether or not the shock criterion is met. Two particular examplesare now described, although more are possible.

As a first example, input 379 can be an input of the motion detectormentioned above. The processor can be configured to determine from atleast the motion detection signal and breathing characteristic 335whether or not the shock criterion is met. For instance, a motiondetection input 379 that includes a sudden motion of large amplitudeduring the day or while walking, followed by lack of any motionthereafter, may indicate SCA, where the patient dropped and has remainedmotionless. In such an instance, motion detection input 379 may also beused for performing operation 380.

The combination of motion detection signal 405 may resolve ambiguities,especially given that the ECG signal is often hampered by electricalnoise. For example, motion detection signal 405 may be used to qualifyan abnormally high detected heart rate, to determine if it is beingcaused by strenuous physical exercise or an emerging illness. Variationsof the raw impedance signal can be analyzed to look for correlatedvariation on the ECG signal to indicate noise caused by electrodemovement. Moreover, the raw, rendered impedance signal used to determinethe respiration rate can be used by the processor's algorithm to helpdetermine if a fast rate detected on the ECG signal is an actual cardiacsignal, or noise that is being caused by movement of the electrodes.Movement of the electrodes may also cause variations in impedance, andif the impedance variation can be correlated to the fast rate seen onthe ECG then that is an indicator the fast rate is actually noise causedby motion and not a VT or VF rhythm. An abnormal respiration rate can beused by the defibrillation therapy algorithm to trigger more processorintensive analysis of the ECG waveforms and other sensor data that wouldnot normally be used in order to conserve battery power.

As a second example, input 379 can be an ECG signal of the patient,which is the input used to determine whether or not the shock criterionis met. For example, a rhythm analysis of the ECG signal may beperformed to determine whether or not the shock criterion is met. Therhythm analysis can be performed in a first manner if it is determinedthat breathing characteristic 335 meets an alert criterion, while therhythm analysis can be performed in a second manner different than thefirst manner otherwise. The alert criterion may be that breathingcharacteristic 335 has a value that is within a safe range, exceeds athreshold, etc. Moreover, the first manner can be different from thesecond manner in a number of ways. For example, the first manner mayinclude a first set of analyses of the ECG signal, while the secondmanner may include the first set of analyses plus at least one moreanalysis that is not included in the first set of analyses.

Examples of different breathing characteristics are now described.

For one example, the breathing characteristic can be a relative tidalvolume. For instance, FIG. 5 is a time diagram 503 of a sample impedancesignal 505. Impedance signal 505 may be as rendered from impedancedetector 222, with or without the aforementioned filtering.

In diagram 503, signal 505 is annotated to illustrate how a breathingcharacteristic 535 may be determined. In particular, a relativeamplitude of impedance signal 505 can be detected, such as thedifference between impedance values IMP1 and IMP2. Then the relativetidal volume can be determined from the detected relative amplitude.

Further variations are possible, for computing a more accurate value ofrelative tidal volume 535. For example, a plurality of relativeamplitudes of the impedance signal may be detected for a predeterminedperiod of time, or for predetermined number of cycles. Then an averagerelative tidal volume may be determined from the plurality of detectedrelative amplitudes, and so on.

For another example, the breathing characteristic can be a respirationinterval or a respiration rate (RR). For instance, FIG. 6 is a timediagram 603 of a sample impedance signal 605. Impedance signal 605 maybe as rendered from impedance detector 222, with or without theaforementioned filtering.

In diagram 603, signal 605 is annotated to illustrate how a breathingcharacteristic 635 may be determined. In particular, a period ofimpedance signal 605 can be detected, such as the difference betweentime values T1 and T2. Then the detected period can be treated as therespiration interval 635. Or, a respiration rate 636 may be determinedfrom the detected period, or from respiration interval 635.

Further variations are possible, for computing a more accurate value forrespiration rate 636. For example, a plurality of periods may bedetected, an average may be taken, and so on as above. In some versions,it may not be possible to detect the respiration rate. Processor 230 maybe further configured to determine whether or not the respiration rateis detectable, and determine that the shock criterion of operation 380is met responsive to the respiration rate not being detectable.

The respiration rate (RR) may be used in combination with other sensorssuch as an accelerometer in the WCD system. For example, in combinationwith activity monitoring from an accelerometer, minimum RR variabilitymay be considered a surrogate of ventilation at rest and maximum RRvariability may be considered a measure of exercise ventilation.Orthopnea or orthopnoea is shortness of breath (dyspnea) that occurswhen lying flat, causing the person to have to sleep propped up in bedor sitting in a chair. Orthopnea or paroxysmal nocturnal dyspnea (PND)may also be assessed from respiration rate assessment in combinationwith night time elevation angle as determined by an accelerometer.

For one more example, the breathing characteristic can be a ventilationthat the patient is receiving. For instance, FIG. 7 is a time diagram703 of a sample impedance signal 705. Impedance signal 705 may be asrendered from impedance detector 222, with or without the aforementionedfiltering.

In diagram 703, signal 705 is annotated to illustrate how a ventilation735 may be determined. In particular, a relative amplitude of impedancesignal 705 can be detected, such as the difference between impedancevalues IMP3 and IMP4. Moreover, a period of impedance signal 705 can bedetected, such as the difference between time values T3 and T4. Thenventilation 735 can be determined from the detected relative amplitudeand from the detected period.

It will be further recognized, also thanks to further annotations inFIG. 7, that ventilation 735 can alternately become known from relativetidal volume 535, respiration interval 635 and respiration rate 636.Moreover, all written above for improvements in computing thesebreathing characteristics may be applied similarly for computingventilation 735.

Additional statistics may be computed for breathing characteristic 335,with or without the added information about motion events that can becontributed by motion detection signal 405. For example, the processormay be further configured to determine a range of acceptable respirationrates of the patient, a minimum respiration rate, a maximum respiration,a median respiration rate, and so on. Trends of these can also bedetected and stored. For example, when these are tracked over a day,week or even longer, they may be used as an indicator of importantphysiologic changes such as dyspnea (a clinical manifestation of heartfailure), or as a predictor for worsening heart failure decompensation.

Alveolar ventilation (a product of respiratory rate and tidal volume) isnormally carefully controlled by the actions of central and peripheralchemoreceptors and lung receptors. Ventilation is driven by both thearterial partial pressure of oxygen (PaO₂) and the arterial partialpressure of carbon dioxide (PaCO₂), with PaCO₂ being the more importantdriver of the two. The body attempts to correct hypoxaemia andhypercarbia by increasing both tidal volume and respiratory rate. Thus,these conditions can be detected by measuring the respiratory rate.

Any condition that causes metabolic acidosis, such as abdominalpathology or sepsis, will also precipitate an increase in tidal volumeand respiratory rate through an increased concentration of hydrogenions, which leads to increased CO₂ production. In addition, otherconditions that could cause hypercarbia or hypoxia may also increasealveolar ventilation. In effect, the respiratory rate can be animportant indicator of a severe derangement in many body systems, notjust the respiratory system, and can therefore be a key predictor ofadverse events.

Of course, not all causes of hypoxia and hypercarbia necessarily resultin an increase in tidal volume and respiratory rate. Medications such asopiates, which are commonly used in hospitals, depress the respiratorydrive and the respiratory response to hypoxia and hypercarbia. In thesecircumstances the respiratory rate can still be a useful tool to monitorfor an adverse event, as the respiratory rate may be lowered, often inassociation with a reduced level of consciousness.

Returning briefly to FIG. 3, as already mentioned above, at operation340 it is optionally determined whether or not breathing characteristic335 meets an alarm condition. Furthermore, at operation 380 it isdetermined whether or not a shock criterion is met. For either one orboth operations 340, 380, in a number of embodiments or versions it canbe determined whether or not breathing characteristic 335 meets an alarmcondition, and the determination of operations 340, 380 can be performedbased at least in part responsive to breathing characteristic 335meeting the alarm condition.

In a number of embodiments or versions, breathing characteristic 335 hasa value, and it can be determined that the breathing characteristicmeets the alarm condition if that value meets a numerical condition.Examples are now described.

FIG. 8 shows how operations 840, 880 may be performed in terms of adiagram 803. Otherwise, operations 840, 880 may be performed asoperations 340, 380 of FIG. 3 respectively.

Diagram 803 shows a single vertical axis with two sample thresholds, TH1and TH2. The breathing characteristic has a value 835 that can beplotted at an appropriate location on the vertical axis, relative tothresholds TH1 and TH2. In other words, the determination of operations840, 880 may be performed by answering the question-mark of dot 835.Accordingly, possible numerical conditions that can be used as acriterion for operations 840, 880 may include that a) value 835 is abovethreshold TH1, b) value 835 is within a range defined by thresholds TH1and TH2, c) value 835 has a value that is below a threshold TH2, d) etc.For example, for respiration rate measurement, such thresholds TH1, TH2etc. may be set in isolation or in combination with other sensors asalso described elsewhere in this document.

Returning briefly to FIG. 3, if at operation 340 the answer is YES then,according to operation 345, a follow-up action may be caused to beexecuted. Examples include that executing the follow-up action includesa) that a record of the alarm condition being met is stored in a memorysuch as memory 238, b) a user interface such as user interface 280outputs a communication to prompt the patient to react as instructed, c)a communication module such as communication module 290 transmits analarm message wirelessly to alert medical personnel or other caregivers,and so on. Indeed, an abnormal respiratory rate has been shown to be animportant predictor of serious events such as cardiac arrest.

In some embodiments, operations 340, 380 are performed responsive to achange in the value of breathing characteristic 335, or in a rate ofchange in the value of breathing characteristic 335. Examples are nowdescribed.

FIG. 9 shows how operations 940, 980 may be performed in terms of adiagram 903. Otherwise, operations 940, 980 may be performed asoperations 340, 380 of FIG. 3 respectively.

Diagram 903 shows a graph 935 that indicates a sample evolution of avalue of the breathing characteristic. At times T11, T12, T13, thebreathing characteristic has values V11, V12, V13 respectively.

In some embodiments, the processor can be configured to determinewhether or not a change in a value of the breathing characteristic meetsa change condition, i.e. whether V12-V11 or V13-V12 meets the changecondition, for example by being larger than a threshold difference. Ifthe change condition is met, the processor may cause a follow-up actionto be executed (operation 940)—the follow-up action can be as above.And/or, if the change condition is met, the determination of whether ornot the shock criterion is met (operation 980) can be performed based atleast in part responsive to the change condition being thus met.

In some embodiments, the processor can be configured to determinewhether or not a rate of change in a value of the breathingcharacteristic meets a rate-of-change condition. In other words,assuming that T12-T11=T13-T12, it can be determined whether or not thecontrast of V13-V12 and V12-V11 meets a rate-of-change condition. Anexample of meeting such a condition is if V13-V12 is larger than V12-V11by a threshold. If the rate-of-change condition is met, the processormay cause a follow-up action to be executed (operation 940)—thefollow-up action can be as above. And/or, if the rate-of-changecondition is met, the determination of whether or not the shockcriterion is met (operation 980) can be performed based at least in partresponsive to the rate-of-change condition being thus met.

In the methods described above, each operation can be performed as anaffirmative step of doing, or causing to happen, what is written thatcan take place. Such doing or causing to happen can be by the wholesystem or device, or just one or more components of it. It will berecognized that the methods and the operations may be implemented in anumber of ways, including using systems, devices and implementationsdescribed above. In addition, the order of operations is not constrainedto what is shown, and different orders may be possible according todifferent embodiments. Examples of such alternate orderings may includeoverlapping, interleaved, interrupted, reordered, incremental,preparatory, supplemental, simultaneous, reverse, or other variantorderings, unless context dictates otherwise. Moreover, in certainembodiments, new operations may be added, or individual operations maybe modified or deleted. The added operations can be, for example, fromwhat is mentioned while primarily describing a different system,apparatus, device or method.

A person skilled in the art will be able to practice the presentinvention in view of this description, which is to be taken as a whole.Details have been included to provide a thorough understanding. In otherinstances, well-known aspects have not been described, in order to notobscure unnecessarily this description.

This description includes one or more examples, but this fact does notlimit how the invention may be practiced. Indeed, examples, instances,versions or embodiments of the invention may be practiced according towhat is described, or yet differently, and also in conjunction withother present or future technologies. Other such embodiments includecombinations and sub-combinations of features described herein,including for example, embodiments that are equivalent to the following:providing or applying a feature in a different order than in a describedembodiment; extracting an individual feature from one embodiment andinserting such feature into another embodiment; removing one or morefeatures from an embodiment; or both removing a feature from anembodiment and adding a feature extracted from another embodiment, whileproviding the features incorporated in such combinations andsub-combinations.

In general, the present disclosure reflects preferred embodiments of theinvention. The attentive reader will note, however, that some aspects ofthe disclosed embodiments extend beyond the scope of the claims. To therespect that the disclosed embodiments indeed extend beyond the scope ofthe claims, the disclosed embodiments are to be considered supplementarybackground information and do not constitute definitions of the claimedinvention.

In this document, the phrases “constructed to” and/or “configured to”denote one or more actual states of construction and/or configurationthat is fundamentally tied to physical characteristics of the element orfeature preceding these phrases and, as such, reach well beyond merelydescribing an intended use. Any such elements or features can beimplemented in a number of ways, as will be apparent to a person skilledin the art after reviewing the present disclosure, beyond any examplesshown in this document.

Any and all parent, grandparent, great-grandparent, etc. patentapplications, whether mentioned in this document or in an ApplicationData Sheet (“ADS”) of this patent application, are hereby incorporatedby reference herein as originally disclosed, including any priorityclaims made in those applications and any material incorporated byreference, to the extent such subject matter is not inconsistentherewith.

In this description a single reference numeral may be used consistentlyto denote a single item, aspect, component, or process. Moreover, afurther effort may have been made in the drafting of this description touse similar though not identical reference numerals to denote otherversions or embodiments of an item, aspect, component or process thatare identical or at least similar or related. Where made, such a furthereffort was not required, but was nevertheless made gratuitously so as toaccelerate comprehension by the reader. Even where made in thisdocument, such a further effort might not have been made completelyconsistently for all of the versions or embodiments that are madepossible by this description. Accordingly, the description controls indefining an item, aspect, component or process, rather than itsreference numeral. Any similarity in reference numerals may be used toinfer a similarity in the text, but not to confuse aspects where thetext or other context indicates otherwise.

The claims of this document define certain combinations andsubcombinations of elements, features and steps or operations, which areregarded as novel and non-obvious. Additional claims for other suchcombinations and subcombinations may be presented in this or a relateddocument. These claims are intended to encompass within their scope allchanges and modifications that are within the true spirit and scope ofthe subject matter described herein. The terms used herein, including inthe claims, are generally intended as “open” terms. For example, theterm “including” should be interpreted as “including but not limitedto,” the term “having” should be interpreted as “having at least,” etc.If a specific number is ascribed to a claim recitation, this number is aminimum but not a maximum unless stated otherwise. For example, where aclaim recites “a” component or “an” item, it means that it can have oneor more of this component or item.

1-58. (canceled)
 59. A method for a wearable cardioverter defibrillator(WCD) system being worn by a patient, the method comprising: receivingan impedance signal indicative of an impedance of the patient;determining, from the impedance signal, a characteristic of breathing bythe patient; receiving an electrocardiogram (ECG) signal of the patient;determining, from at least the breathing characteristic and analysis ofthe ECG signal, whether or not a shock criterion is met; furthercomprising: storing a baseline value for the breathing characteristic;computing a difference of a current value of the breathingcharacteristic and the stored baseline value; and determining at leastin part that the shock criterion is met responsive to the computeddifference of the current value and stored baseline value being largerthan a threshold; analyzing the ECG signal in a first manner when thebreathing characteristic meets an alert criterion; determining at leastin part that the shock criterion is met responsive to the ECG analysisin the first manner; analyzing the ECG signal in a second mannerdifferent from the first manner when the breathing characteristic doesnot meet the alert criterion; and determining at least in part that theshock criterion is met responsive to the ECG analysis in the secondmanner; and responsive to the shock criterion being met, delivering ashock to the patient.
 60. The method of claim 59, further comprising:filtering the impedance signal to derive a filtered impedance signal, inwhich the breathing characteristic is determined from the filteredimpedance signal.
 61. The method of claim 60, further-comprising:identifying variations in the impedance signal, in which filtering theimpedance signal comprises removing the impedance signal variations thathave a frequency greater than a threshold.
 62. The method of claim 60,in which filtering the impedance signal comprises removing impedancesignal variations that repeat over a period of at least 30 seconds. 63.The method of claim 60, further comprising: identifying variations in abaseline of the ECG signal; identifying variations in the impedancesignal; and filtering the impedance signal wherein the filteringcomprises removing from the rendered impedance signal variations thatare concurrent with the identified variations of the ECG signal.
 64. Themethod of claim 60, further comprising: receiving a motion detectionsignal indicative of a motion of the patient, identifying variations areidentified in the motion detection signal; identifying variations in theimpedance signal; and filtering the impedance signal wherein thefiltering comprises removing from the impedance signal variations thatare concurrent with the identified variations in the motion detectionsignal.
 65. The method of claim 59, in which the WCD system furtherincludes a memory; and further comprising: storing the current andbaseline values of the breathing characteristic in the memory. 66.(canceled)
 67. The method of claim 59, further comprising: receiving amotion detection signal indicative of a motion of the patient, whereinthe baseline value is determined from a portion of the impedance signaland the motion detection signal.
 68. The method of claim 59, furthercomprising: receiving a motion detection signal indicative of a motionof the patient and determining from at least the motion detection signaland the breathing characteristic whether or not the shock criterion ismet. 69.-71. (canceled)
 72. The method of claim 59, in which thebreathing characteristic comprises a relative tidal volume, and furthercomprising: detecting a relative amplitude of the impedance signal; anddetermining the relative tidal volume from the detected relativeamplitude.
 73. The method of claim 59, in which the breathingcharacteristic comprises a respiration interval, and further comprising:detecting a period of the impedance signal; and treating the detectedperiod as the respiration interval.
 74. The method of claim 59, in whichthe breathing characteristic comprises a respiration rate, and furthercomprising: detecting a period of the impedance signal; and determiningthe respiration rate from the detected period.
 75. The method of claim74, further comprising: determining whether or not the respiration rateis detectable; and determining that the shock criterion is met at leastin part responsive to the respiration rate not being detectable.
 76. Themethod of claim 59, in which the breathing characteristic comprises aventilation, and further comprising: detecting a relative amplitude ofthe impedance signal; detecting a period of the impedance signal; anddetermining the ventilation from the detected relative amplitude andfrom the detected period.
 77. The method of claim 59, furthercomprising: determining whether or not the breathing characteristicmeets an alarm condition; and causing a follow-up action to be executedresponsive to determining that the alarm condition is thus met.
 78. Themethod of claim 77, in which the breathing characteristic meets thealarm condition if the breathing characteristic has a value that meets anumerical condition.
 79. The method of claim 77, in which the WCD systemfurther includes a memory, and executing the follow-up action includesstoring a record of the alarm condition being met in the memory.
 80. Themethod of claim 77, in which the WCD system further includes a userinterface, and executing the follow-up action includes that the userinterface outputs a communication.
 81. The method of claim 77, in whichthe WCD system further includes a communication module, and executingthe follow-up action includes that the communication module transmits analarm message.
 82. The method of claim 59, further comprising:determining whether or not the breathing characteristic meets an alarmcondition, and in which the determination of whether or not the shockcriterion is met is performed based at least in part responsive to thebreathing characteristic meeting the alarm condition.
 83. The method ofclaim 82, in which the breathing characteristic meets the alarmcondition if the breathing characteristic has a value that meets anumerical condition.
 84. The method of claim 59, further comprising:determining whether or not a change in a value of the breathingcharacteristic meets a change condition; and causing a follow-up actionto be executed responsive to determining that the change condition isthus met.
 85. The method of claim 59, further comprising: determiningwhether or not a rate of change in a value of the breathingcharacteristic meets a rate-of-change condition; and causing a follow-upaction to be executed responsive to determining that the rate-of-changecondition is thus met.
 86. The method of claim 59, further comprising:determining whether or not a change in a value of the breathingcharacteristic meets a change condition, and in which the determinationof whether or not the shock criterion is met is performed based at leastin part responsive to the change condition being thus met.
 87. Themethod of claim 59, further comprising: determining whether or not arate of change in a value of the breathing characteristic meets arate-of-change condition; and in which the determination of whether ornot the shock criterion is met is performed based at least in partresponsive to the rate-of-change condition being thus met.